Classical Hodgkin's lymphoma with cutaneous involvement in an adolescent male: A case study

Abstract Background Hodgkin's lymphoma (HL) with skin involvement is reasonably rare. It typically occurs late in the course and is associated with a poor prognosis; however, it may also be indolent in some cases. Case We report a case of a 15‐year‐old previously healthy male with Hodgkin's lymphoma who presented with multiple lymphadenopathies of axilla and serpiginous ulcerative nodular lesions involving pectoral skin. A lymph node biopsy was performed following an initial diagnostic workup for a suspected active infectious disease, which revealed a neoplastic invasion from a mixed cellularity classical HL with skin involvement. A total of six cycles of ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) chemotherapy regimen was administered to the patient. Conclusion In comparison to other studies, this case demonstrates that a good response is possible with standard ABVD chemotherapy.

Fusion PET/CT imaging was performed from the vertex of skull to mid thigh 60 mins after IV administration of 4.3 mCi of F-18 fluorodeoxyglucose (FDG). CT was performed for the purpose of attenuation correction and anatomical correction. Blood glucose level was 124 mg/dl prior to scan.

Head & Neck
Increased FDG uptake is noted in the enlarged left supraclavicular node (SUV max 10.4). Physiological FDG uptake is noted in the rest of head and neck. No significant FDG avid cervical nodes are seen.
Increased FDG uptake is noted in the large pleural based deposit in the left internal mammary region (SUV MAX 11.5).

Increased FDG uptake is noted in the pleural based deposits in both hemithorax (SUV max 9.3)
Increased FDG uptake is noted in the deposits noted is bilateral pectoralis muscle (SUV max right 10.4; left 7.7) Increased FDG uptake is noted in the cutaneous and subcutaneous deposits in anterior chest wall (SUV max 9.3)

No significant FDG uptake is noted in fissural nodule in left hemithorax
No abnormal FDG uptake is noted in the rest of lungs.

Abdomen & Pelvis
No abnormal FDG uptake is seen in the liver, spleen, gallbladder, pancreas, kidneys and adrenals.
No significant FDG avid abdominal, pelvic or inguinal nodes are seen.

Bone
No demonstrable abnormal FDG uptake noted in the bones and bone marrow.

PET -CT IMPRESSION
Anterior chest wall skin lesions (HPE -fungal infection ),axillary lymphadenopathy (Biopsy-Lymphoma), for evaluation 1) Hypermetabolic cutaneous and subcutaneous lesions in anterior chest wall. 2) Hypermetabolic supraclavicular axillary and mediastinal nodes 3) Hypermetabolic anterior chest wall muscle deposits. 4) Hypermetabolic pleural deposits in bilateral hemithorax. 5) No other demonstrable metabolically active disease elsewhere in the whole body survey. Inj. BLEOMYCIN16 U dissolve in 5 ml NS and administer as a show iv push over 10 minutes Inj. VINBLASTINE 9.6 mg iv push in running saline Inj. DACARBAZINE 600mg in 500ml 5% Dextrose over 2 hour(use separate line)

After Chemotherapy
After first dose of Chemotherapy  Classical Hodgkin's lymphoma, post 2 cycles of chemotherapy ( last dose on 8 -5-2019) , deep fungal infection in anterior chest wall, on antifungal, for response evaluation.

CT FINDINGS
Multislice (64 slice) serial axial section of head and mid thigh were studied without administration of IV and oral contrast

Brain
Cerebral neuroparenchyma shows normal attenuation, enhancement and gray white matter differentiation. Brain stem and cerebellum are normal. Ventricles and cisterns are normal. Calvarium shows no destructive lesion.

Head and Neck.
Base of skull, orbits, paranasal sinuses, naso-, oro-and hypopharynx and larynx are normal .
Bilateral carotid arteries and jugular veins are normal .Prominent left supraclavicular lymph node measuring 0.9 x 0.4 The parotid and submandibular glands are normal. Thyroid glands are normal.
Significant regression in the multiple ill-defined soft tissue and subcutaneous, cutaneous deposits are seen in the anterior chest wall muscles. Larger cutaneous soft tissue deposits are also seen in the chest wall, largest measures 4.0 x 2.5 cms.

Resolution of the nodular pleural thickening is also seen in the bilateral upper hemithorax. No evidence of pleural effusion.
Lungs show no suspicious mass or nodules.
The cardia, pulmonary trunk and aorta are normal. No pericardial effusion.

Abdomen and Pelvis
Liver is normal in size. No focal lesion is seen her liver. No intra hepatic biliary radicle dilatation. Portal vein, hepatic veins and IVC are normal.
Gall bladder, spleen, pancreas, adrenals and both kidneys are normal.
No significant paraaorticadenopathy.No mesenteric or peritoneal deposits . No ascites.
The urinary bladder, prostate and seminal vesicles are normal.

PET REPORT:
Fusion PET/CT imaging was performed from the vertex of skull to mid thigh 60 mins after IV administration of 4.9mCi of F-18 fluorodeoxyglucose (FDG). CT was performed for the purpose of attenuation correction and anatomical correction. Blood glucose level was 92 mg/dl prior to scan.

No significant FDG uptake is seen in the prominent left supraclavicular node [Deauville's score l].
Non FDG avid bilateral level ll cervical nodes are seen-likely reactive Physiological FDG uptake is noted in the rest of head and neck.
Low grade FDG uptake is noted in the deposits noted in bilateral pectoral muscle (SUV max2.6 on left) and cutaneous, subcutaneous deposits in anterior chest wall (SUV max 2.6).
No significant FDG uptake is noted in fissural nodule in left hemithorax.
No abnormal FDG uptake is noted in the rest of lungs.

Abdomen & Pelvis
No abnormal FDG uptake is seen in the liver, spleen, gallbladder, pancreas, kidneys and adrenals.
FDG distribution in the bowel loops is in a physiological pattern.
No significant FDG avid abdominal, pelvic or inguinal nodes are seen.

Bone
No demonstrable abnormal FDG uptake noted in the bones and bone marrow.

PET -CT IMPRESSION
Classical Hodgkin's lymphoma, post 2 cycles of chemotherapy (last dose on 08-05-2019), deep fungal infection in anterior chest wall, on antifungals, for response evaluation.

CLINICAL HISTORY
Classical Hodgkin's lymphoma, deep fungal infection in anterior chest wall, on antifungal, post 6 cycles of chemotherapy (last dose on 28 -08-2019 ), for evaluation

CT FINDINGS
Multislice (64 slice) serial axial section of head to mid thigh were studied withput administration of IV and oral contrast

Brain
Cerebral neuroparenchyma shows normal attenuation, enhancement and gray white matter differentiation. Brain stem and cerebellum are normal. Ventricles and cisterns are normal. Calvarium shows no destructive lesion

HEAD AND NECK
No significant cervical adenopathy .
Bilateral carotid arteries and jugular veins are normal .
The parotid and submandibular glands are normal. Thyroid glands are normal.

CHEST
There is further regression in size of the supraclavicular, bilateral axillary, subpectoral ,deep pectoral, bilateral internal mammary and pervascular nodes are seen, largest left internal mammary nodal mass extending into the left chest wall measures 1.2x1.0cms, previously measured 1.5x 1.5cms and left axillary node measures 1.0x0.8cms, previously measured 1.3x1.2cms,Stable multiple ill definedsoft tissue and subcutaneous, cutaneous deposits are seen in the anterior chest wall, larger cutaneous soft tissue deposits measures 4.0 x1.2cms,previously measured 4.0x 2.5cms No pleural effusion.
Abdomen and pelvis